Rissolo Patient Registration

PATIENT REGISTRATION INFORMATION

Mr. Mrs. Ms. Dr.

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

Height

Weight

SSN

Email

Address

City

State

Zip Code

Home Phone

Cell Phone

Student Status

Full Time Part Time Not a Student

School Name

Have you ever been a patient of our practice?

Yes No

Has a family member ever been a patient of our practice?

Yes No

Referred By

Dentist

Medical Doctor

Orthodontist

Who will be responsible for your account?

Other

Responsible Person First Name

Responsible Person Last Name

SSN

Date of Birth

Age

Telephone

Address

City

State

Zip Code

Employer

Business Phone

Spouse or other guarantor information (if different from above)

First Name

Last Name

SSN

Relation

Date of Birth

Telephone

Address

City

State

Zip Code

Employer

Business Phone

EMERGENCY CONTACT

First Name

Last Name

Home Telephone

Work Telephone

Cell Phone

Insurance Information

Primary Dental Insurance Company

Do you have dental insurance?

Yes No

Primary Policy Holder

Primary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

Primary Medical Insurance Company

Do you have medical insurance?

Yes No

Primary Policy Holder

Primary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

Secondary Dental Insurance Company

Do you have secondary dental insurance?

Yes No

Secondary Policy Holder

Secondary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

Secondary Medical Insurance Company

Do you have secondary medical insurance?

Yes No

Secondary Policy Holder

Secondary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

For Women Only

Is there a possibility of pregnancy?

Yes No

If yes, what trimester?

First Second Third

Expected Delivery

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

Form Completion

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's health). It is my responsibility to inform the dental office of any changes in medical status.

If Patient is a Minor

Form signed by:

Relationship to Patient:

Date

Authorization

Patient Signature (Parent or Guardian if minor)

Clear

Clear

Online Signature×

Draw your signature inside the box Clear